Author + information
- Peter Tajti, MD,
- M. Nicholas Burke, MD,
- Dimitri Karmpaliotis, MD,
- Khaldoon Alaswad, MD,
- Gerald S. Werner, MD,
- Lorenzo Azzalini, MD, PhD, MSc,
- Mauro Carlino, MD,
- Mitul Patel, MD,
- Kambis Mashayekhi, MD,
- Mohaned Egred, MD,
- Oleg Krestyaninov, MD,
- Dmitrii Khelimskii, MD,
- William J. Nicholson, MD,
- Imre Ungi, MD, PhD,
- Alfredo R. Galassi, MD,
- Subhash Banerjee, MD and
- Emmanouil S. Brilakis, MD, PhD∗ ()
- ↵∗Minneapolis Heart Institute, 920 East 28th Street #300, Minneapolis, Minnesota 55407
We are grateful to Dr. Mohaved for his insightful comments on our paper (1). A point by point response follows:
1. The EXPLORE (Evaluating Xience and Left Ventricular Function in Percutaneous Coronary Intervention on Occlusions After ST-Elevation Myocardial Infarction) trial. We agree that chronic total occlusion (CTO) percutaneous coronary intervention (PCI) should not be performed in most patients presenting with ST-segment elevation myocardial infarction during the index hospitalization, even though the CTO PCI success rates in the study (73%) were significantly lower than those currently achieved at experienced centers.
2. The DECISION-CTO (Drug-Eluting Stent Implantation Versus Optimal Medical Treatment in Patients With Chronic Total Occlusion) trial was not a trial of CTO PCI versus medical therapy, but a trial in which most patients had multivessel disease and a CTO. It is unclear whether patients had ischemia or symptoms after non-CTO lesions were treated and why the crossover from medical therapy to CTO PCI (in 18% of patients) was not counted as part of the primary endpoint (death, myocardial infarction, or revascularization).
3. In the EuroCTO trial (A Randomized Multicentre Trial to Evaluate the Utilization of Revascularization or Optimal Medical Therapy for the Treatment of Chronic Total Coronary Occlusions), CTO PCI was associated with better quality of life at 12 months compared with medical therapy, as assessed by the Seattle Angina Questionnaire angina frequency (p = 0.003) and quality of life (p = 0.007).
4. Reference 5 was an abstract, not a publication. We agree that there are limited data that CTO PCI can reduce subsequent death or myocardial infarction, and suggest that “the primary indication for offering and performing CTO PCI should be the alleviation of symptoms.”
5. “Validity of comparison between successful and failed CTO PCI”: As mentioned in our review, “such analyses have multiple inherent limitations”; that is why we did not discuss these studies.
6. “Failed to mention many negative large observational studies”: Reference 8 is a single-center observational study; we only included multicenter studies in our review. Reference 9 compares successful versus failed CTO PCI, which as discussed in the preceding text is an invalid comparison.
7. “CTO PCI is a very costly and risky procedure with no clear benefit, it should only be performed in very selected rare cases of severe refractory angina. However, this type of scenario is extremely rare.” We respectfully disagree with several aspects of this statement. The average risk of CTO PCI is approximately 3%, which for many patients is perfectly acceptable (97% chance to not have a complication). CTO PCI is more costly than non-CTO PCI; however medical therapy can also be costly, as can be subsequent medical care. There is clear symptomatic benefit of CTO PCI, based on the best available data (Euro CTO trial). Many of us see several patients who benefit from CTO PCI in everyday practice.
CTO PCI has substantially evolved in recent years with increasing success and decreasing complication rates. CTO PCI is a tool, as is medical therapy and surgical revascularization, both of which are chosen for several patients with CTOs.
We believe that “CTO PCI should be performed when the anticipated benefits exceed the potential short- and long-term risks,” which is true for all medical interventions. We also believe that our mission as physicians is to help each patient make this determination by presenting both sides of the equation in an objective and balanced fashion.
Please note: Dr. Burke has received consulting and speaker honoraria from Abbott Vascular and Boston Scientific. Dr. Karmpaliotis has received speaker honoraria from Abbott Vascular, Medtronic, Boston Scientific, and Vascular Solutions. Dr. Alaswad has received consulting fees from Terumo and Boston Scientific; and has been an (unpaid) consultant for Abbott Laboratories. Dr. Werner has received speaker honoraria for Asahi Intecc, Abbott Vascular, Biosensors, and Terumo; and has been the principal investigator of a randomized trial on the benefit of CTO PCI versus medical therapy conducted by the EURO CTO Club sponsored by Asahi Intecc and Biosensors. Dr. Patel has received consulting honoraria from Abbott Vascular. Dr. Mashayekhi has received honoraria from Asahi Intecc. Dr. Nicholson has been a proctor or served on the Speakers Bureau/Advisory Board of Abbott Vascular, Boston Scientific, and Asahi Intecc; and holds intellectual property in Vascular Solutions. Dr. Banerjee has received research grants from Gilead and The Medicines Company; received consultant/speaker honoraria from Covidien and Medtronic; holds intellectual property in HygeiaTel; and his spouse has ownership in DCARE Global. Dr. Brilakis has received consulting/speaker honoraria from Abbott Vascular, ACIST Medical Systems, Amgen, Asahi Intecc, CSI, Elsevier, GE Healthcare, Medicure, Medtronic, and Nitiloop; received research support from Boston Scientific and Osprey; served on the board of directors of Cardiovascular Innovations Foundation; and served on the board of trustees of Society of Cardiovascular Angiography and Interventions. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- 2018 American College of Cardiology Foundation